Editorial

"THE CUCKOO'S NEST" AND OUR IMAGE

"One Flew Over the Cuckoo's Nest" is a popular film, and rightly so. It is full of humor and tragedy about human conflicts within the mental health delivery system. It has won more Academy Awards than any other movie since the mid-1930's. Box office receipts remain high and it is because of its popularity that mental health professionals should be concerned about the image portrayed in the movie of psychiatry and the mental health delivery system.

Psychiatry and, in particular, psychiatrists, have generally been portrayed most unfavorably by movies and television. The image of psychiatry often presented to the public is that of a person who is odd or funny; eccentric at best, and at the worst, sick himself. (Recently there have been a number of books critical of psychiatry - a psychiatrist, E. Fuller Torrey, provides the most recent attack in "Death of Psychiatry", which is reviewed in this issue of the Journal.)

It is this Editor's contention that psychiatry has enough of an image problem without a continuation of the negative portrayal often made by movies and television shows of the profession. Mental health professionals should protest this stereotyping of the psychi- atric profession and encourage a more positive image of psychiatry by the media.

"Cuckoo's Nest", however, is not an indictment of psychiatry. "One Flew Over the Cuckoo's Nest" is an indictment of the failures and abuses of administration. It is the administrator in the system, "Big Nurse", (Played by Louise Fletcher) who manipulates the system as she wills. By subverting all positive management philos- ophies relating to self-determination, democratic principles, group decisions, and the rule of majority, Big Nurse maintained absolute power on the ward. Effective management to her mind meant that the patients did as she wished, while giving the appearance that they did as they wished. Big Nurse sustained a strict social order through the use of a system of rewards and (occasionally sordid) punish- ments. Typical of the more severe of the latter were electroshock therapy and Iobotomies. Nor did Big Nurse have any compunction whatsoever about assaulting a patient's individual vulnerable spot. One guilt-ridden fragile patient was driven to suicide in this way. But, Big Nurse was only successful in her manipulations due to an additional aspect of administrative abuse: abdication of responsibility by administrators in the higher echelons. The ward psychiatrist, the superintendent, and other administrators on up permitted Big Nurse to manage the system in whatever manner she chose, as long as it ran smoothly. The well-being of the patients had little priority.

Admittedly, "Cuckoo's Nest" reflects the mental health system of 20 years ago. Ken Kesey's book was copyrighted in 1962 and must have described conditions existing in a mental hospital in the late 1950's. In most mental health care delivery systems today, the acutely ill patient is not on the same ward with the chronic schizophrenic. Electric shock therapy is tightly controlled, supervised and reviewed. Lobotomies are prohibited in many areas and are so tightly regulated in others that they are rarely carried out. Certainly most mental health professionals today would agree that the treatment program as described in the movie has materially improved since the late 1950's.

On the other hand, "Cuckoo's Nest" does accurately portray "administration". Certainly there are administrators today who subvert and manipulate the policies, rules, and regulations of the organization to attain their own personal ends. The manipulation of the objectives of the organization to place priority on one's own personal objective is called sub-optimization. It is, to say the least, undersirable, and should be stringently avoided by administrators.

Administrators should be concerned about the image of the profession of administration as portrayed by movies and television. The first step in attaining a positive image of the profession of administration is for the practitioners in administration to be sensitive to the image problem, to be effective in their profession or role, and to be alert to the need to avoid being seen by others as a "Big Nurse".